“We’ve got to reduce the cost of health care.” I hear this year after year. A few things are done to slow down the relentless rise — King County’s wellness programs, for example — but the trend is still up. Obamacare, which America is going to have in some form no matter who is elected, is unlikely to change it.

The Affordable Care Act is about insurance. It defines a minimum level of coverage, requires that people buy it and provides some with money for buying it. In economic terms, it raises demand.

The rap on it is that it has no control of costs. That is by design. It wouldn’t have passed otherwise. All costs are somebody’s revenue, and the medical industry does not want its revenue limited. Ordinary Americans don’t want their medical care limited, either. They want the best.

Americans spend more than 17 percent of national output on medical care, a level higher than any other big country. Canada spends about 11 percent. It has a single-payer system, which gives its provincial governments the sort of cost-control power that Americans have been unwilling to have wielded over them.

Here is the difference. A month ago a friend who lives in Victoria had his prostate removed because of cancer. Under British Columbia’s single-payer system, he could have had it done by a surgeon, with a long cut on the abdomen. That is the old way. My friend wanted it done the new way, using a U.S.-made robotic-assisted laparoscopic machine.

This octopus-like machine, called the da Vinci Surgical System, is less invasive and usually shortens the hospital stay and recovery time (though it didn’t in my friend’s case). The machine costs about $1.5 million. Its maker says Canada has only one machine within 100 miles of Vancouver, at Vancouver General Hospital.

My friend asked to go there. He was told to wait. He would also have to pay $5,600, because British Columbia considers robotic-assisted laparoscopy a nonstandard procedure.

In the United States, it is the standard. Within 100 miles of Seattle, 23 hospitals have da Vinci machines, and some medical practices have their own. Most U.S. patients for prostate operations are covered by private insurance or Medicare, but there are cash customers, some of them fleeing the system in Canada. Swedish Medical Center in Seattle quoted my friend a price of $30,000. His appointment at Vancouver General came through, and he had the work done there.

His wife was suffering earlier this year from a 90-percent blocked artery. She needed an angioplasty with a drug-emitting stent. Because she was otherwise in good health, the Canadian system put her on an indefinite wait.

She gave up waiting and paid Virginia Mason Medical Center $26,000. A month after her operation in Seattle, her Canadian provider called and said there had been a cancellation. She could come in.

That is the Canadian system. It gets most of the same results as ours for a lot less money. It is more egalitarian, more spartan and less customer-friendly. It puts patients in queues of indefinite length. It is not a first user of new technology, and relies on Americans to pay most of the cost of new drugs and devices.

Americans have a different system. Obamacare will modify it, but it is unlikely to bring down the cost. It is not clear that the cost of medical care can be substantially brought down in any way people here would accept.